VA Healthcare System (VISN 10)

Issue: A volunteer working in the My HealtheVet program is believed to have falsely authenticated approximately 29 Veterans who did not enrolling the program. Update: 05/20/13:Notificatoin letters will be sent to 29 Veterans.…

Outcome: NA

Issue: It was reported to the ISO that Patient A came to the facility and requested a wheelchair for use while in the facility. The Voluntary Service manages issuing wheelchairs and issued Patient A a wheelchair. Upon arrival to the patient's…

Outcome: Credit Monitoring Letter. Checked Training and Awareness; however, it is more just awareness in alerting the two areas to be more diligent in even checking if patients may leave PHI laying around or "stuck" to something. S. Leister/PO…

Issue: Veteran A was seen in Primary Care Team and asked for a copy of his medications. When he got home and showed his wife, she noticed that the information belonged to Veteran B. Full name, full SSN and medications were…

Outcome: Staff reeducated on correct procedure for releasing medications from the clinics.Request that this ticket be closed

Issue: Veteran A received Veteran B Health Benefits Renewal Form and VA return envelope in the mail. Veteran A returned all documents to CBOC. Update: 04/10/13:Veteran B will be sent a letter offering credit protection services.04/16/13:Update - Veteran A will also…

Outcome: Employee was counseled by supervisor and Credit Monitoring Letters have been mailed to patients.

Issue: A copy of the lab draw list was found on the floor in the hallway. The list contained 4 patients' name, full SSN and lab results. Update: 04/09/13:The 4 patients will receive a letter offering credit protection services.05/28/13:This was determined…

Outcome: Alternate PO spoke with Lab Personnel re. this incident to prevent similar incidents from occurring in the future. Staff reminded to secure all documents containing phi at all times. Request that this ticket be closed. Thank you.…

Issue: Records pertaining to a Veteran were included with records mailed to another Veteran. Update: 04/05/13:Due to full SSN and medical information being exposed, Veteran B will be sent a letter offering credit protection services.…

Outcome: Employee who mailed the information was appropriately counseled.

Issue: Veteran A was discharged and picked-up his discharge medications, but did not get one item that was refrigerated. The discharge pharmacist noticed this and asked a technician to mail the refrigerated item to Veteran A. The technician instead of picking…

Outcome: Technician was trained on the importance of checking for correct Veteran medication prior to mailing out.

Issue: Two Veterans brought in appointment letters, which they received in the mail. The letters belonged to other Veterans. Update: 04/01/13:Two Veterans will be sent a letter offering credit protection services.05/22/13:This was determined to be HITECH reportable by VHA Privacy Office.…

Outcome: Mailroom staff advised to closely monitor mail process - particularly envelopes that are stuffed by machines to prevent PHI from being mailed to unauthorized recipients.

Issue: A Veteran and his wife were seen at a Community Based Outpatient Clinic (CBOC). The clerk allowed the Veteran's wife to sign consent form to get copy of the Veteran's lab work. The wife had no authority to sign for…

Outcome: Clerk instructed in process of releasing medical records. Authorization must be obtained from veteran or legal surrogate - wife is not considered legal surrogate (other she has other legal authority).Request that this ticket be closed.…

Issue: Employee A stated when filing taxes he/she noticed having the W2 Form of Employee B. When W2 Form of Employee B was returned no one could find Employee A's W2 Form. Update: 03/27/13:Employee A will be sent a letter offering…

Outcome: Spoke to employee concerning the misplacement of W2 Form. I informed employee of the importance of securing all information that pertains PII/PHI, we spoke of alternatives to securing such information due to the frequent traveling of employees from CBOC to…